Thank you to everyone who responded to our March Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
April Quandary: Fourteen-year-old client Tyler’s parents brought him to me for therapy recently because of what they interpret as antisocial behavior. They say he rarely engages with classmates or teachers, isn’t interested in extracurricular activities, and heads straight to his room after school to play video games. They worry he’s depressed. Part of me wants to nudge Tyler toward more social behavior, but he’s mostly responsive in therapy and insists he’s happy. Is this just the moody teenage years at work? What should I do?
1) Put the Client in the Driver’s Seat
The first thing I would do is uncover Tyler’s reasons for why he’s engaging less at school and spending his evenings playing video games. If we believe that behavior always serves a function, then we should seek to understand the function behind his actions. If I was Tyler’s therapist, I’d start by asking him, “What’s the most important part of playing video games for you? What do you really get out of it? What’s the worst that could happen if you couldn’t play anymore?” Revealing the function behind the behavior is key to changing it.
If Tyler insists he’s fine and happy, it’s time to turn to some strategic questions that will help put him in the driver’s seat and in problem-solving mode, rather than in a more passive state where I simply nudge him to be more social. To do this, I might ask, “Tyler, what do you think your parents are most concerned about? What do you think we could do to help ease their worries? If your parents could know just one or two things about how you see this problem, what would you want them to know?”
When possible, I like to have these kinds of conversations in joint sessions with teens and their parents, as a way of both empowering the teen and enlightening the parents. Often, I find that teens will open up to me even with parents in the room, and it’s a relief for them to be able to do so.
If Tyler is in fact depressed, there are several things I’d want to look for, namely changes in changes in his family system, or in his sleep, appetite, mood, medications, or academic performance. If any of this applies, I’d want to know whether these changes coincided with Tyler being less sociable and playing video games more.
Of course, we have to remember that many teens socialize through online video games. For them, this can be normal social behavior. If that’s the case with Tyler, I’d shift to helping his parents understand this new platform for socialization.
Zachary Taylor, MA, LPC, NCC
2) Take the Pressure Off
Personally, if I was Tyler’s therapist, I’d shy away from trying to nudge him in the direction of social or extracurricular activities, especially since it sounds like his parents may already be doing this. Instead, I’d want to take the pressure off him. I can only imagine how Tyler feels coming to therapy at his parents’ insistence. He might think something’s wrong with him, which is why my main goal would be to create a safe, comfortable space where he can relax, chat, and maybe have a little fun.
However, I don’t want to rule out a problem entirely. I have a hunch Tyler could’ve experienced some sort of trauma, or that there’s something in his environment that’s causing him to retreat inward. To assess this, I might say something to Tyler like, “Sometimes bad things can happen to us in life that might cause us to act differently. I’ve been wondering if there have been situations in your life that might be causing you to act or respond in a way that backfires. You know, when something uncomfortable happens in my life, I often like to find a place where I can get away from whatever’s causing me to feel that way.”
There’s a children’s book by Margaret Holmes called A Terrible Thing That Happened, which is intended for young kids who’ve experienced violence, trauma, accidents, and other disasters. Even though Tyler’s a little older than the book’s intended audience, I might read it to him as a way of communicating how traumatic occurrences can cause us to react differently in our day-to-day lives.
Andrew Dill, MSW, LSW
3) Invite Conversation, Not Conflict
There’s no nudging Tyler here. His nonparticipation and body language are saying “not interested.” Pushing an agenda will show him that either you’re not reading him correctly, or you are but are still choosing to ignore his message. In either case, you’ve lost him.
I see Tyler’s parents as the only active change agents for now, so if I was Tyler’s therapist, I’d begin talking with them about his gaming. This topic is the best portal to a conversation that can touch on Tyler’s mental health, disconnection in his family, and the need for parameters. I’d want Tyler to be present during this conversation too, making it clear that he’s welcome to speak but under no obligation to do so.
Tyler’s gaming isn’t my central concern, but a discussion about limiting access will do several things: put the issue of addiction front and center, likely elicit a response from Tyler, highlight any connection between excessive gaming and Tyler’s depressed mood and isolation, and increase opportunities for Tyler’s family members to interact.
Tyler and his parents will need help knowing how to interact with one another in ways that invite conversation rather than conflict. To that end, I’d model for Tyler’s parents a way of talking that expresses goodwill and an authentic wish to reconnect, helping them say right there in session: “Tyler, we’re struggling as a family, and I think we’ve forgotten how to talk with one another. We’re used to you being in your room all the time, and you’re probably used to us pouncing on you with questions because we feel so in the dark about you. It doesn’t feel good to us, and probably doesn’t for you either. We miss you and want to change things so we can enjoy hanging around each other again.”
What jumps out at me in this case is the disconnect between Tyler and his parents, and between Tyler and the rest of the world. By healing the former, he’ll have the best chance at healing the latter.
Janet Sasson Edgette, PsyD
4) Explore Context
Tyler’s situation sounds strikingly familiar to that of the teen clients I see in my practice. But calling this “the moody teenage years at work” doesn’t sufficiently address his parents’ concerns, nor does it account for the disparity between how he reportedly behaves at home and what he says in therapy. When a client’s behavior differs across settings, I explore context: What’s different for Tyler when he’s in my office as opposed to when he’s at home? What do his parents mean by “antisocial” behavior—is he just distant or is he aggressive and hostile? What does he find more enjoyable about gaming than relating with others in real time?
Much of my approach is informed by family systems. If Tyler’s parents insist there’s a problem, but Tyler insists there isn’t, then family discussions might illuminate the issues and help us come up with solutions. Tyler may be wrong in saying there’s no problem, but he’d be correct in saying it’s not his problem alone. The problem resides in the current dynamic between him and his parents, which means his parents need to join us in therapy. I might ask them things like, “Mom and Dad, what would you need to see in order to feel reassured about Tyler’s socialization and mood? Tyler, do you think your parents’ requests are reasonable? If not, what about them would need to change? Is there anything your parents might not know about gaming that could reassure them that you’re actually socializing and feeling happy?”
Upon reaching some basic understanding of everyone’s needs, motives, and desires, we’d be in a position to identify a solution that each family member finds satisfactory and can work toward. Maybe Tyler’s parents decide that his gaming is benign so long as it doesn’t keep him up all night, or if it’s mixed with engagement with friends, teachers, and family members. Assuming Tyler embraces this idea, it can serve as a litmus test to determine whether his parents are unnecessarily concerned or whether he’s “faking good” in our sessions and is actually depressed.
Joe Dilley, PhD
Sierra Madre, CA
5) Examine the Web of Relationships
In order to establish if whether Tyler’s behavior is a result of “moody teenage years” at work, I’d want to hold a session with the whole family in order to better understand Tyler’s parents’ interpretation of his behavior. I’d also want to explore what Tyler thinks about that interpretation.
In our therapy together, I’d be curious about why Tyler’s parents worry he’s depressed. Has his behavior changed recently? Are there any other changes they’re concerned about? Has anything happened in the family that could be influencing this? Is Tyler engaging with people online? If so, perhaps he has connections through the video games he plays that his parents aren’t aware of.
Next, I’d explore relationships within Tyler’s family. Is his parents’ relationship stable? Does Tyler have any siblings? If so, what are these other relationships like? What do Tyler’s teachers say about how he’s doing at school in terms of his work ethic and peer relationships?
Last, Tyler’s parents might benefit from a little psychoeducation to help them understand the difference between normal teenage behavior and mental health problems. As his parents, they’re in a good position to notice any warning signs, and may need help communicating more effectively with their son.
Geraldine McKay, MSW
We'll post a new response to each Clinician's Quandary on the first Tuesday of every month! See how to submit to next month's Quandary here.
May Quandary: Diedre was widowed about 2 years ago. She starts telling her therapist about a new man she’s dating and is so excited. The sex is wild and they’re spending all of their time together. Her therapist slowly begins to realize that this is the same man another client used to date. He was great at first, the sex was wild, and then he slowly became controlling and abusive. It ended terribly. Is it appropriate to share this information?
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